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Medical Intel

Jan 29, 2019

Rheumatoid arthritis causes inflammation that primarily affects joints in the hands, feet, and ankles. While treatment was limited to managing pain years ago, new medications now can prevent further joint damage and restore patients’ functionality.



Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re speaking with Dr. Konstantinos Loupasakis, a rheumatologist at MedStar Washington Hospital Center. Thank you for joining us today, Dr. Loupasakis.

Dr. Konstantinos Loupasakis: Thank you for having me.

Host: Today we’re discussing rheumatoid arthritis, or RA, a chronic inflammatory condition that affects the joints of the hands and feet. Dr. Loupasakis, what does inflammatory mean when it comes to rheumatoid arthritis?

Dr. Loupasakis: Inflammatory means that the affected parts of the body, which are usually the joints: the hands the feet, the ankles, the knees. The parts of the body that are affected by rheumatoid arthritis display signs of inflammation. inflammation is a reaction of the body. It’s a reaction of the immune system which is the part of the body that defends ourselves against injury or infection. The signs of inflammation usually include pain, swelling, warmth, and limited range of motion. Also, stiffness, which is particularly prominent in the morning hours.

Host: What are some of the most common symptoms of rheumatoid arthritis?

Dr. Loupasakis: So, the most common symptoms are pain, stiffness, warmth, and swelling of the joints and the typical joints that are affected are the small joints of the hands, the wrist, the feet, and the ankles, but also larger joints such as the knees, the elbows, and the shoulders. It’s very important to note that in addition to the joint pains, rheumatoid arthritis can affect the whole body. It’s a systemic inflammatory disease, so it’s not just a disease of the joints. It can cause inflammation of vital organs, sometimes, and it can also affect the blood vessels and that’s why it’s been recently recognized as a factor for accelerated cardiovascular disease.

Host: When a patient comes to you with rheumatoid arthritis symptoms, do they look differently or is it just how they feel?

Dr. Loupasakis: It can be both. That depends on how severe the rheumatoid arthritis is and it depends how long they’ve had it for. So, if the rheumatoid arthritis has been persistent for many years and it hasn’t been recognized and hasn’t been treated, the patients can look ill. They might have lost weight, they might have felt very weak for a very long time, and in general, they might have been very fatigued, which has affected both their physical function, but also their psychological and emotional states.

Host: I was thinking about the swelling of the joints. Do they get large enough that they would be visibly swollen? Do they become red?

Dr. Loupasakis: That can happen. That usually depends on the size of the joints that are affected. For example, the small joints of the hands, it’s less easy, let’s say, for a non-rheumatologist to recognize the swelling. For us, it’s pretty easy when we examine our patients to even acknowledge even small changes in the normal size of the joint. But to the patients, usually sometimes that’s not something that is striking aside from the pain and the stiffness that they experience in the morning. However, larger joints such as the knees, they can accumulate a lot of fluid in a short amount of time and that can be very obvious, even to the patients or their relatives, their family members, sometimes.

Host: Could you describe your patient population for RA? Who’s most at risk?

Dr. Loupasakis: Rheumatoid arthritis typically affects women two to three times more frequently compared to men. The age range that we usually see is, ranges between 20s and 30s. It can also occur at a second wave in the 60s or 70s.

Host: Why is it that RA affects such a young population?

Dr. Loupasakis: We don’t know. What we know is that there is a genetic predisposition, there is a genetic component to this disease. So depending on the risk factors that the patients have in addition to that genetic predisposition, the manifestation of clinical disease can happen earlier or later in life. The peak age onset is usually the 50s, but we do have patients in their 20s and 30s as well as patients in their 60s and 70s. But it’s not really known why this disease affects the age groups that we just discussed. What is important to note is that oftentimes people confuse rheumatoid arthritis with osteoarthritis. And osteoarthritis is predominantly a disease of the elderly. It’s a different kind of arthritis and it’s not inflammatory - it’s what we call degenerative which means wear and tear or overuse arthritis. So, the frequency of osteoarthritis is much higher in the ages of 60s and 70s. Especially in people that have risk factors such as being overweight or having done too much physical workout when they were younger. So what people call arthritis, in general, oftentimes refers to osteoarthritis and I think that gets commonly confused with rheumatoid arthritis, which typically affects younger patients or middle-aged patients.

Host: How is rheumatoid arthritis diagnosed?

Dr. Loupasakis: Rheumatoid arthritis is diagnosed by a combination of a very thorough and careful physical exam, history taking by a specialist, a rheumatologist, in combination with blood and urine tests, and occasionally with X-Rays of the joints that have been affected. There is no single specific test that can confirm the diagnosis, but there are certain tests that, if they are positive in conjunction with a history that is convincing and a physical exam that is positive for joint swelling, signs of inflammation such as the warmth, the swelling, the tenderness, all of these things together in the right age group, that can give us the clue and that can lead to the diagnosis of that disease.

Host: Is there anything patients can do to reduce their risk for RA?

Dr. Loupasakis: That’s a great question. Science has recently revealed some risk factors that we didn't’ know in the past. For example, smoking is a very significant risk factor for the development of RA. Especially in patients who have had some genetic predisposition. Let’s say, patients who have had rheumatoid arthritis in the family history. They’ve had a first degree relative with rheumatoid arthritis. So, smoking is a risk factor that may increase their chances of developing active disease. Another risk factor is poor oral hygiene, poor dentition. And that’s very important to note because both of these are modifiable risk factors, so our patients can prevent those risk factors from contributing to their development of the disease.

Host: That’s very interesting. I wouldn’t think that smoking or dental health would affect your joints. How do you explain that to patients when you’re talking through that?

Dr. Loupasakis: There are very complex immunologic mechanisms that underlie this concept. There is a scientific explanation that has to do with alterations, changes that happen in normal tissue, normal cells, in the mouth or in the lungs and those changes that happen because of the irritation that smoking or the, let’s say, the bacteria in the mouth in patients who may not take very good care of their oral hygiene. That irritation can lead to the stimulation of the immune system and that stimulation of the immune system which starts outside of the joint, let’s say in the mouth or in the lungs, under certain circumstances and triggers can eventually transition into the joint and cause inflammation of the joint. It’s a concept that has only been recently recognized and it’s fascinating.

Host: Is the smoking or the dental health factor only for individuals that have a hereditary risk, or could it be for anyone?

Dr. Loupasakis: It could be for everyone because the genetic predisposition is not necessarily something that the patient knows that they have. The genetic predisposition is more obvious when patients come to us knowing that a family member has a history of rheumatoid arthritis, but it can still be there, and they may not have been aware of that.

Host: What treatments are available for RA?

Dr. Loupasakis: I’m very excited to discuss this topic with you because things have really changed for the better in the recent years. Scientific breakthroughs have really led to the development of really effective medications and these medications have really revolutionized the care of our patients. We used to have only corticosteroids, what most people know as cortisone. And we still use it for patients that have very bad flares because they work very quickly, and they can cool things down very easily and very quickly in a short period of time. However, these days we have a great range of other medications, some of them in tablet form, patients can take them by mouth. Others as an injection that patients can self-administer at home. And then there’s a third category of medications that are administered as an IV infusion, for which our patients have to make an appointment and come to the infusion center.

Host: What are the long-term health consequences if RA is left untreated?

Dr. Loupasakis: That depends on the severity of RA. However, we know that rheumatoid arthritis has the potential to really cause significant damage to the joints and that can lead to permanent disability especially when the joints get stiff, limited range of motion, and deformed. That shouldn’t really happen in these days because of the availability of all these treatments that we have that are very effective. However, unfortunately we still see that sometimes. It’s a problem that has to do with access to care, but it’s strongly recommended that all patients with rheumatoid arthritis should be treated promptly because in addition to the joints, rheumatoid arthritis can affect the whole body. It’s a systemic inflammatory disease and it can affect other vital organs including the heart and the vessels and that’s why it’s important to treat it very early so that it doesn’t cause changes to these organs which can potentially lead to development of many other problems aside from the arthritis itself.

Host: When a person’s RA symptoms are really acting up, that’s called a flare. Could you explain what that process is like for the patient?

Dr. Loupasakis: Sure. Rheumatoid arthritis is a disease with relapses and remissions. What that means is that even if the patient does everything correctly, they take their medications very consistently, they take very good care of themselves and their health, they follow up with us on a regular basis as they should, their disease can still become more active from time to time for reasons that are not exactly very well understood. Sometimes a viral infection such as the flu or the common cold can trigger their immune system to become more active and under those circumstances the rheumatoid arthritis can flare. When that happens, the patients can feel worsening pain in the usually affected joints - their hands, their feet, their wrists, their ankles - it’s usually the same joints that bother them every time their arthritis is active, so those joints can become more stiff, especially in the morning, they can get more warm, they can get more painful, and that’s what we usually call a flare. This can happen in a very short period of time, usually within a few days and unless it’s treated, sometimes it can last for many weeks or even months. So, it’s very important when that happens that these patients communicate those findings to their rheumatologist because they will have to be reevaluated in the office and their medication regimen might need to be modified.

Host: So, you mentioned there are all of these different sorts of advanced treatments that are available to patients now. Maybe ten, fifteen years ago what would the options have been for a patient?

Dr. Loupasakis: Very few. And it is unfortunate because we still see patients who developed rheumatoid arthritis many years ago and unfortunately, since those treatments had not been available back then, we are in the unfortunate position to see deformities that have already happened in their joints. Thankfully we don’t really see those patients anymore. Patients we diagnose these days, they almost never progress to the extent that they would develop deformities in the joints. The patients that were diagnosed with rheumatoid arthritis, let’s say twenty years ago, the medications that we had back then were not as effective and the options were very limited. So, cortisone and maybe a few different types of tablet form medications that were not that effective and therefore they were not enough to prevent the rheumatoid arthritis from causing damage to the joints. So unfortunately, a lot of these patients ended up progressing and developing joint deformities and joint damage that limited the function of the hands.

Host: Would it be fair to say that treatments have progressed from just symptom management to really treating and preventing damage with this disease?

Dr. Loupasakis: I think that would be a very fair statement. It is true that with the older medications we would try to just treat the symptoms, the pain, but we would not necessarily target the source of the pain which is the inflammation itself and, also, we were not able to target the pathways that make the inflammation happen. Because of that, those medications they could potentially mask the symptoms, they could potentially make the patients feel a little bit better without slowing down the progression of the disease, so these patients oftentimes would still have a lot of joint damage down the line.

Host: Could you share a treatment success story from your patient population?

Dr. Loupasakis: Sure. I have quite a few, thankfully, I guess that’s a good thing. But I will never forget a woman in her 50s with severe rheumatoid arthritis. She had been treated with many different medications including high doses of cortisone and even though she would have brief periods of relief of her symptoms, she had never been able to go into what we call remission, a very persistent low disease state. She would always have flares every few weeks. She wasn’t able to enjoy her life. She had lost her functional capacity and she was really depressed. Thankfully, we have had so many newer treatments coming out and of course my patient had been discouraged, understandably, but knowing that improvement of her disease is possible, I wasn’t discouraged, and I tried to maintain the optimism in her treatment plan and I kept trying different medications. At this point, I have to highlight the importance of time. Her medications did not kick in right away and I think that this is something very important for our patients to remember, that sometimes these medications can take from a few weeks up to three months to really kick in. So that’s what we did with my patient. We kept trying different medications until we found a medication that was the right fit for her. And her disease dramatically improved. Her joint swelling and pain went away. She became much more functional again. She was able to enjoy her life with her family and with her grandchildren and she was really the happiest person. She was extremely thankful, and her depression really went away.

Host: It’s clear that you really care about your patients a lot. When they’re in that time frame where they’re waiting for their medication to become more effective, how do you help them stay positive and how do you help them manage their pain?

Dr. Loupasakis: We try to follow a multidisciplinary approach. We work closely with other subspecialties and we’re really open to referring these patients to psychotherapists, psychiatrists, to support groups, and we can provide them with resources in order to make that happen. I think it’s very important, it’s a very important part of the treatment because these are chronic diseases. They have long lasting symptoms and it’s understandable that a lot of our patients can be very depressed because their life changes because of the pain and because of the loss of function. So, until we get them back in good shape, which hopefully happens in most of the cases these days, it is important to maintain a sense of optimism and support them emotionally and psychologically in order to go through that very unfortunate and unpleasant phase.

Host: Once a patient has found a medication that’s working for them and they’re really on the road to recovery, what sort of outcomes can they expect? Will they go back to a full functionality? Back to work, back to exercise and enjoying their hobbies?

Dr. Loupasakis: The outcomes really range from complete restoration of their functionality to a reasonable improvement that would allow them to go back to some of their activities, but maybe not all of them. That depends, oftentimes, on how severely affected their joints have been. For example, if they have developed very severe damage to their hands or the knees, even if we take care of the inflammation, we can improve the pain significantly, but maybe the damage sometimes may not allow for a full restoration of their functional capacity. We really try our best to maximize the effect of our treatments, also combining that with physical therapy. And I think that’s very important because it really strengthens the muscles, it increases the range of motion of the affected joints, and in combination with the treatments that we provide, oftentimes we see very good outcomes with patients being able to go back to running, swimming, and playing sports. Depending on what they like to do. Sometimes maybe with some modifications in their activity, maybe the level of their activity can be a little bit decreased or they can modify the equipment that they use. For example, we can use some in-soles for patients with severe arthritis in the knees. Anything to minimize the impact in the affected joints.

Host: Can weather or the environment affect a person’s RA symptoms?

Dr. Loupasakis: It is a very interesting question because it is true that, I would say, even most of our patients have noticed changes in their pain and in their stiffness depending on the weather conditions. So even though it’s not easy to study those things in a structured clinical study, it’s something that our experience shows that it does happen. It’s not entirely understood why, but it’s been speculated that changes in the atmospheric pressure, sometimes that are associated with weather changes, can affect the joints and for reasons that are not entirely understood, patients can experience more pain during the winter months.

Host: Why is MedStar Washington Hospital Center the best place to seek care for rheumatoid arthritis?

Dr. Loupasakis: What the rheumatology division and my colleagues in this hospital do, is that we all strive for multidisciplinary approach and we all try to provide the best care that we can based on the needs of our patients. We are very up to date about the newest treatments. We educate the future rheumatologists of the area - we have the teaching hospital and we want to be on the cutting edge of the treatments and the scientific progress that have been accomplished in our field. That, and also the fact that we work with orthopedic surgeons, physical therapists, radiologists, to achieve the best outcomes for our patients.

Host: Thanks for joining us today, Dr. Loupasakis.

Dr. Loupasakis: Thank you. It was my pleasure.

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